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CPT codes:

22554Arthrodesis: anterior interbody: w/ diskectomy; cervical below C2
25990Arthrodesis: posterior technique: craniocervical
22600Arthrodesis: posterior/posterolateral technique: single level; cervical below C2

ICD-9 codes:

721Spondylosis and allied disorders
721.0Cervical spondylosis without myelopathy
Cervical or cervicodorsal:
Arthritis
Osteoarthritis
Spondylarthritis
721.1Cervical spondylosis with myelopathy
Anterior spinal artery compression syndrome
Spondylogenic compression of cervical spinal cord
Vertebral artery compression syndrome
721.7Traumatic spondylopathy
722Intervertebral disc disorders
722.0Displacement of cervical intervertebral disc without myelopathy
Neuritis (brachial) or radiculitis due to displacement or rupture of cervical intervertebral disc
Any condition classifiable to 722.2 of the cervical or cervicothoracic intervertebral disc
722.0Displacement of intervertebral disc, site unspecified, without myelopathy
Discogenic syndrome NOS
Herniation of nucleus pulposus NOS
Intervertebral disc NOS:
  Extrusion
  Prolapse
  Protrusion
  Rupture
Neuritis or radiculitis due to displacement or rupture of intervertebral disc
722.4Degeneration of cervical intervertebral disc
805Fracture of vertebral column without mention of spinal cord injury
Includes:
  Neural arch
  Spine
  Spinous process
  Transverse process
  Vertebra
The following fifth-digit subclassification is for use with codes:
  0 cervical vertebra, unspecified level
  1 first cervical vertebra
  2 second cervical vertebra
  3 third cervical vertebra
  4 fourth cervical vertebra
  5 fifth cervical vertebra
  6 sixth cervical vertebra
  7 seventh cervical vertebra
  8 multiple cervical vertebrae
805.0Cervical, closed
  Atlas
  Axis
805.1Cervical, open

Cervical Arthrodesis

  • Editor(s): Todd W Thomsen, MD, Gary S Setnik, MD, FACEP
  • Section Editor(s): Phillip M Harter, MD
  • Contributor(s): Carmie Chan, MD
PRE-PROCEDURE
INDICATIONS
  • Cervical disc disease
  • Cervical spondylosis with or without myelopathy
  • Unstable cervical fractures
  • Cervical instability from other causes:
    • Rheumatoid arthritis
    • Traumatic quadriparesis
    • Neoplastic spinal metastasis
    • Congenital abnormalities
CONTRAINDICATIONS

There are no absolute contraindications to this procedure.
EQUIPMENT
  • Operating microscope
  • High-speed bur
  • Small-angled curets
  • Small Kerrison rongeurs
  • Micro-blunt hook
  • Micro-blunt dissector
  • Blunt hand-held retractors
  • Bipolar electrocautery
  • Distraction pins
  • Self-retaining retractor
  • No. 11 blade scalpel
  • Pituitary rongeurs
  • Curets
  • Kocher clamp
  • Small oscillating saw
  • Bone wax
ANATOMY
  • Surface anatomy
    • Hyoid bone (C3), thyroid cartilage (C4-C5), cricoid cartilage (C6)
  • Muscles encountered in the dissection:
    • Platysma, sternocleidomastoid, omohyoid, longus colli, digastric, stylohyoid
  • Neurovascular structures at risk:
    • Carotid artery, sympathetic ganglia, recurrent laryngeal nerve, superior laryngeal nerve, hypoglossal nerve, pharyngeal and laryngeal branches of the vagus nerve

PROCEDURE
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  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
TECHNIQUES
  • Post-Procedure: Anterior Cervical Arthrodesis (Smith-Robinson Technique)
  • Post-Procedure: Anterior Cervical Arthrodesis (Bailey and Badgley Technique)
  • Post-Procedure: Anterior Cervical Arthrodesis (Simmons' Technique)
  • Post-Procedure: Anterior Occipitocervical Arthrodesis by Extrapharyngeal Exposure (deAndrade and Macnab Technique)
  • Post-Procedure: Anterior Occipitocervical Arthrodesis by Extrapharyngeal Exposure (Robinson and Riley Technique)

Post-Procedure: Anterior Cervical Arthrodesis (Smith-Robinson Technique)

POST-PROCEDURE CARE
  • Remove drain on postoperative day 1.
  • Bracing and mobilization vary by technique:
    • Smith-Robinson or Simmons' technique: rigid cervical orthosis for 4 to 6 weeks (discectomy) or 8 to 12 weeks (corpectomy); soft cervical collar for an additional 1 to 2 weeks.
    • Discontinue orthosis when fusion visible on radiographs.
    • Bailey and Badgley technique: halo brace for 3 months followed by 4 to 6 weeks in a cervical collar.
  • Early patient mobilization is allowed on the surgical day or postoperative day 1.
  • If fibular strut grafting is used, postoperative immobilization may need to be prolonged.
COMPLICATIONS
  • Spinal cord injury
  • Other neurologic injury (recurrent laryngeal nerve)
  • Dural tears
  • Fusion of incorrect vertebral level
  • Sympathetic nervous system injury
  • Dysphagia
  • Dysphonia
  • Airway obstruction secondary to the development of a retropharyngeal hematoma
  • Vertebral body collapse (seen most often with multilevel dowel technique, which is no longer used)
  • Pseudarthrosis
ANALYSIS OF RESULTS
  • Anterior cervical fusion has shown good results with all of the techniques described; Smith-Robinson technique strongest in terms of compressive load.
  • Complication rates are generally low; most common are nerve injury and pseudarthrosis.
  • Pseudarthrosis rates are reduced by using internal fixation.
OUTCOMES AND EVIDENCE
  • Apfelbaum et al: laryngeal nerve compression may be caused by endotracheal tube position combined with tracheal retraction; the incidence was decreased by deflating and reinflating the endotracheal tube cuff after retractor placement.
  • One prospective study reported a 50% frequency of dysphagia at 1 month after surgery; at 6 months, only 4.8% had moderate to severe dysphagia.
  • Dysphonia has been reported to be around 4% to 5%.
  • With multilevel interbody fusions, the pseudarthrosis rate increases nonlinearly.
  • Wang et al: the addition of internal fixation for two-level anterior cervical discectomy and fusion significantly reduced the pseudarthrosis rate.
  • In another study, there was no difference in fusion rates between single-level cervical corpectomy and two-level discectomy and fusion when anterior plating was used.
  • Smoking has been shown to increase the pseudarthrosis rate following posterolateral lumbar grafting.
  • Hilibrand et al: smoking had a negative impact on healing after multilevel anterior fusion with autogenous interbody graft without internal fixation. No difference was seen when corpectomy was done.
  • Bose et al: no difference in fusion rates between smokers and nonsmokers for multilevel anterior cervical decompression and fusion when anterior plating was used.
  • White et al: Robinson and Smith configuration is the strongest in compressive loading.
Procedure: Anterior Cervical Arthrodesis (Smith-Robinson Technique)

Post-Procedure: Anterior Cervical Arthrodesis (Bailey and Badgley Technique)

POST-PROCEDURE CARE
  • Remove drain on postoperative day 1.
  • Bracing and mobilization vary by technique:
    • Smith-Robinson or Simmons' technique: rigid cervical orthosis for 4 to 6 weeks (discectomy) or 8 to 12 weeks (corpectomy); soft cervical collar for an additional 1 to 2 weeks.
    • Discontinue orthosis when fusion visible on radiographs.
    • Bailey and Badgley technique: halo brace for 3 months followed by 4 to 6 weeks in a cervical collar.
  • Early patient mobilization is allowed on the surgical day or postoperative day 1.
  • If fibular strut grafting is used, postoperative immobilization may need to be prolonged.
COMPLICATIONS
  • Spinal cord injury
  • Other neurologic injury (recurrent laryngeal nerve)
  • Dural tears
  • Fusion of incorrect vertebral level
  • Sympathetic nervous system injury
  • Dysphagia
  • Dysphonia
  • Airway obstruction secondary to the development of a retropharyngeal hematoma
  • Vertebral body collapse (seen most often with multilevel dowel technique, which is no longer used)
  • Pseudarthrosis
ANALYSIS OF RESULTS
  • Anterior cervical fusion has shown good results with all of the techniques described; Smith-Robinson technique strongest in terms of compressive load.
  • Complication rates are generally low; most common are nerve injury and pseudarthrosis.
  • Pseudarthrosis rates are reduced by using internal fixation.
OUTCOMES AND EVIDENCE
  • Apfelbaum et al: laryngeal nerve compression may be caused by endotracheal tube position combined with tracheal retraction; the incidence was decreased by deflating and reinflating the endotracheal tube cuff after retractor placement.
  • One prospective study reported a 50% frequency of dysphagia at 1 month after surgery; at 6 months, only 4.8% had moderate to severe dysphagia.
  • Dysphonia has been reported to be around 4% to 5%.
  • With multilevel interbody fusions, the pseudarthrosis rate increases nonlinearly.
  • Wang et al: the addition of internal fixation for two-level anterior cervical discectomy and fusion significantly reduced the pseudarthrosis rate.
  • In another study, there was no difference in fusion rates between single-level cervical corpectomy and two-level discectomy and fusion when anterior plating was used.
  • Smoking has been shown to increase the pseudarthrosis rate following posterolateral lumbar grafting.
  • Hilibrand et al: smoking had a negative impact on healing after multilevel anterior fusion with autogenous interbody graft without internal fixation. No difference was seen when corpectomy was done.
  • Bose et al: no difference in fusion rates between smokers and nonsmokers for multilevel anterior cervical decompression and fusion when anterior plating was used.
  • White et al: Robinson and Smith configuration is the strongest in compressive loading.
Procedure: Anterior Cervical Arthrodesis (Bailey and Badgley Technique)

Post-Procedure: Anterior Cervical Arthrodesis (Simmons' Technique)

POST-PROCEDURE CARE
  • Remove drain on postoperative day 1.
  • Bracing and mobilization vary by technique:
    • Smith-Robinson or Simmons' technique: rigid cervical orthosis for 4 to 6 weeks (discectomy) or 8 to 12 weeks (corpectomy); soft cervical collar for an additional 1 to 2 weeks.
    • Discontinue orthosis when fusion visible on radiographs.
    • Bailey and Badgley technique: halo brace for 3 months followed by 4 to 6 weeks in a cervical collar.
  • Early patient mobilization is allowed on the surgical day or postoperative day 1.
  • If fibular strut grafting is used, postoperative immobilization may need to be prolonged.
COMPLICATIONS
  • Spinal cord injury
  • Other neurologic injury (recurrent laryngeal nerve)
  • Dural tears
  • Fusion of incorrect vertebral level
  • Sympathetic nervous system injury
  • Dysphagia
  • Dysphonia
  • Airway obstruction secondary to the development of a retropharyngeal hematoma
  • Vertebral body collapse (seen most often with multilevel dowel technique, which is no longer used)
  • Pseudarthrosis
ANALYSIS OF RESULTS
  • Anterior cervical fusion has shown good results with all of the techniques described; Smith-Robinson technique strongest in terms of compressive load.
  • Complication rates are generally low; most common are nerve injury and pseudarthrosis.
  • Pseudarthrosis rates are reduced by using internal fixation.
OUTCOMES AND EVIDENCE
  • Apfelbaum et al: laryngeal nerve compression may be caused by endotracheal tube position combined with tracheal retraction; the incidence was decreased by deflating and reinflating the endotracheal tube cuff after retractor placement.
  • One prospective study reported a 50% frequency of dysphagia at 1 month after surgery; at 6 months, only 4.8% had moderate to severe dysphagia.
  • Dysphonia has been reported to be around 4% to 5%.
  • With multilevel interbody fusions, the pseudarthrosis rate increases nonlinearly.
  • Wang et al: the addition of internal fixation for two-level anterior cervical discectomy and fusion significantly reduced the pseudarthrosis rate.
  • In another study, there was no difference in fusion rates between single-level cervical corpectomy and two-level discectomy and fusion when anterior plating was used.
  • Smoking has been shown to increase the pseudarthrosis rate following posterolateral lumbar grafting.
  • Hilibrand et al: smoking had a negative impact on healing after multilevel anterior fusion with autogenous interbody graft without internal fixation. No difference was seen when corpectomy was done.
  • Bose et al: no difference in fusion rates between smokers and nonsmokers for multilevel anterior cervical decompression and fusion when anterior plating was used.
  • White et al: Robinson and Smith configuration is the strongest in compressive loading.
Procedure: Anterior Cervical Arthrodesis (Simmons' Technique)

Post-Procedure: Anterior Occipitocervical Arthrodesis by Extrapharyngeal Exposure (deAndrade and Macnab Technique)

POST-PROCEDURE CARE
  • Remove drain on postoperative day 1.
  • Bracing and mobilization vary by technique:
    • Smith-Robinson or Simmons' technique: rigid cervical orthosis for 4 to 6 weeks (discectomy) or 8 to 12 weeks (corpectomy); soft cervical collar for an additional 1 to 2 weeks.
    • Discontinue orthosis when fusion visible on radiographs.
    • Bailey and Badgley technique: halo brace for 3 months followed by 4 to 6 weeks in a cervical collar.
  • Early patient mobilization is allowed on the surgical day or postoperative day 1.
  • If fibular strut grafting is used, postoperative immobilization may need to be prolonged.
COMPLICATIONS
  • Spinal cord injury
  • Other neurologic injury (recurrent laryngeal nerve)
  • Dural tears
  • Fusion of incorrect vertebral level
  • Sympathetic nervous system injury
  • Dysphagia
  • Dysphonia
  • Airway obstruction secondary to the development of a retropharyngeal hematoma
  • Vertebral body collapse (seen most often with multilevel dowel technique, which is no longer used)
  • Pseudarthrosis
ANALYSIS OF RESULTS
  • Anterior cervical fusion has shown good results with all of the techniques described; Smith-Robinson technique strongest in terms of compressive load.
  • Complication rates are generally low; most common are nerve injury and pseudarthrosis.
  • Pseudarthrosis rates are reduced by using internal fixation.
OUTCOMES AND EVIDENCE
  • Apfelbaum et al: laryngeal nerve compression may be caused by endotracheal tube position combined with tracheal retraction; the incidence was decreased by deflating and reinflating the endotracheal tube cuff after retractor placement.
  • One prospective study reported a 50% frequency of dysphagia at 1 month after surgery; at 6 months, only 4.8% had moderate to severe dysphagia.
  • Dysphonia has been reported to be around 4% to 5%.
  • With multilevel interbody fusions, the pseudarthrosis rate increases nonlinearly.
  • Wang et al: the addition of internal fixation for two-level anterior cervical discectomy and fusion significantly reduced the pseudarthrosis rate.
  • In another study, there was no difference in fusion rates between single-level cervical corpectomy and two-level discectomy and fusion when anterior plating was used.
  • Smoking has been shown to increase the pseudarthrosis rate following posterolateral lumbar grafting.
  • Hilibrand et al: smoking had a negative impact on healing after multilevel anterior fusion with autogenous interbody graft without internal fixation. No difference was seen when corpectomy was done.
  • Bose et al: no difference in fusion rates between smokers and nonsmokers for multilevel anterior cervical decompression and fusion when anterior plating was used.
  • White et al: Robinson and Smith configuration is the strongest in compressive loading.
Procedure: Anterior Occipitocervical Arthrodesis by Extrapharyngeal Exposure (deAndrade and Macnab Technique)

Post-Procedure: Anterior Occipitocervical Arthrodesis by Extrapharyngeal Exposure (Robinson and Riley Technique)

POST-PROCEDURE CARE
  • Remove drain on postoperative day 1.
  • Bracing and mobilization vary by technique:
    • Smith-Robinson or Simmons' technique: rigid cervical orthosis for 4 to 6 weeks (discectomy) or 8 to 12 weeks (corpectomy); soft cervical collar for an additional 1 to 2 weeks.
    • Discontinue orthosis when fusion visible on radiographs.
    • Bailey and Badgley technique: halo brace for 3 months followed by 4 to 6 weeks in a cervical collar.
  • Early patient mobilization is allowed on the surgical day or postoperative day 1.
  • If fibular strut grafting is used, postoperative immobilization may need to be prolonged.
COMPLICATIONS
  • Spinal cord injury
  • Other neurologic injury (recurrent laryngeal nerve)
  • Dural tears
  • Fusion of incorrect vertebral level
  • Sympathetic nervous system injury
  • Dysphagia
  • Dysphonia
  • Airway obstruction secondary to the development of a retropharyngeal hematoma
  • Vertebral body collapse (seen most often with multilevel dowel technique, which is no longer used)
  • Pseudarthrosis
ANALYSIS OF RESULTS
  • Anterior cervical fusion has shown good results with all of the techniques described; Smith-Robinson technique strongest in terms of compressive load.
  • Complication rates are generally low; most common are nerve injury and pseudarthrosis.
  • Pseudarthrosis rates are reduced by using internal fixation.
OUTCOMES AND EVIDENCE
  • Apfelbaum et al: laryngeal nerve compression may be caused by endotracheal tube position combined with tracheal retraction; the incidence was decreased by deflating and reinflating the endotracheal tube cuff after retractor placement.
  • One prospective study reported a 50% frequency of dysphagia at 1 month after surgery; at 6 months, only 4.8% had moderate to severe dysphagia.
  • Dysphonia has been reported to be around 4% to 5%.
  • With multilevel interbody fusions, the pseudarthrosis rate increases nonlinearly.
  • Wang et al: the addition of internal fixation for two-level anterior cervical discectomy and fusion significantly reduced the pseudarthrosis rate.
  • In another study, there was no difference in fusion rates between single-level cervical corpectomy and two-level discectomy and fusion when anterior plating was used.
  • Smoking has been shown to increase the pseudarthrosis rate following posterolateral lumbar grafting.
  • Hilibrand et al: smoking had a negative impact on healing after multilevel anterior fusion with autogenous interbody graft without internal fixation. No difference was seen when corpectomy was done.
  • Bose et al: no difference in fusion rates between smokers and nonsmokers for multilevel anterior cervical decompression and fusion when anterior plating was used.
  • White et al: Robinson and Smith configuration is the strongest in compressive loading.
Procedure: Anterior Occipitocervical Arthrodesis by Extrapharyngeal Exposure (Robinson and Riley Technique)
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